Intake Form 

Please print this page and bring it to your first session along with a signed copy of the policies on the previous page. If you have a medical referral you can text a photo to me or bring it along with your copies of the policies and Client Intake forms.

Client Consent and Questionnaire                         

Name_______________________________________________________________________________

Address _____________________________________________________________________________

 ____________________________________________________________________________________                                 

____________________________________________________________________________________

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Best phone number____________________________________

Best email ___________________________________________

Name of emergency contact: ______________________________________

Their phone ___________________________ email ________________

Relationship:  ____________________________________________

 Do they live with you? Yes_______  NO__________

Briefly describe the reason for your visit.____________________________________________

____________________________________________________________________________

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____________________________________________________________________________

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How long have you had this discomfort or situation ______________

Do you have a doctor or chiropractor’s referral for medical massage?     yes______    no______

How did you find me?     _______________________________________

Do you have any ongoing health issues, such as diabetes, heart disease, depression for which you take medication?

Please list:__________________________________________________________________________   

Covid-19 Related Questions

1.Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days?

2. Have you been tested for COVID-19?   NA______  If so, when?    _____ /____/____

a. What was the result?      Positive_____   Negative______

3. In the last 14 days:

1. Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath, or other respiratory problems, new, or strange symptoms)?   

2. Yes______   No______

       If yes, please describe___________________________________________________

5. Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms?  Yes______   No______

6. Have you been tested for COVID-19?

      a. if so, when  ______/______/_____

      b. What was the result?    positive _______  negative_____   

7. Have you been somewhere with a high infection rate in the last 2 weeks?   Yes_______   No______

8. Have you been to any unmasked gatherings, such as political rallies, beaches, schools, or parties in the last 14 days?      Yes_____   No_____

9. I have seen the policies under "Other" on this site and I agree to abide by them.  Yes_______    No_______  

For everyone’s well-being:

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I acknowledge that while precautions are taken for my safety, any bodywork, or in-person meeting carries inherent risks. By coming to an appointment I am accepting these risks.     Yes_______    No_______

Should any answers to the previous questions change, I agree to inform Ms. Peltier immediately.   Yes____  No___

Furthermore, if I have a temperature above 100.2°F on the day of the appointment, or have developed cold or flu-like symptoms since scheduling the appointment, I agree to inform Ms. Peltier and postpone my session? 

Yes_______   No _______

I also agree that should I fail to inform Ms. Peltier of any changes to my health prior to my appointment, or I have a temperature of 100 degrees or more upon arrival, she has the right to refuse service.    

Yes________   No__________

I agree to these conditions and affirm the truth of my statements:  Yes______

Signature:  __________________________________________________________  

Date___________   

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